An Overview of Visceral Manipulation

The purpose of visceral manipulation is to recreate, harmonize, and increase proprioceptive communication in the body, in order to enhance its internal mechanism for optimum health. Visceral manipulation is organ-specific fascial mobilization, and is based on the premise that free movement within the body is vital, and thus any restriction will adversely affect health. Visceral manipulation treats functional and structural imbalances throughout the body, with an aim to affect musculoskeletal, vascular, nervous, urogenital, respiratory, digestive, and lymphatic dysfunction. It evaluates and treats the dynamics of motion and suspension in relation to organs, membranes, fascia, and ligaments and increases proprioceptive communication within the body, thereby revitalizing it, and relieving symptoms of pain, dysfunction, and poor posture.

Visceral manipulation relies on the palpation of normal and abnormal forces within the body, with the specific goal of encouraging normal tone and movements, both within and between the internal organs, their connective tissue, and other structures of the body where normal motion has been impaired [1]. By using precise manual techniques, such as palpation of the superficial and deep fascia and the mobility and motility of individual organs, therapists can evaluate how abnormal forces interplay, overlap, and affect the normal body forces at work [1]. The goal of visceral manipulation is to help the body return to normal function and thereby remove compensatory symptoms, whatever their source, leading to improved health and optimal body functioning.

REFERENCES

1. Barral JP, Mercier P. Manipulations viscerales. Maloine, Paris, France: Elsevier; 1983.

The osteopath Jean-Pierre Barral was introduced to the concept of visceral manipulation while working as a physical therapist at the Lung Disease Hospital in Grenoble, France, where he met Georges Arnaud, a specialist in lung disease and cadaver dissection. With Arnaud, Barral studied the patterns of stress in the tissues of cadavers together with the biomechanics of living subjects [1]. This introduced him to the visceral system, its potential to promote lines of tension within the body, and the notion that tissues have memory [2]. Using his work with Arnaud as a foundation, Barral continued to investigate how the thickening of tissues in the body created areas of greater mechanical tension that, in turn, pulled on surrounding tissues. His discoveries led him to the theoretical and practical development of 'visceral listening techniques' [2], whereby when 'listening', the therapist's hands remain totally passive, while sensing and evaluating the axis and amplitude of visceral motility.

Working primarily with articular and structural manipulation, Barral began forming the basis for visceral manipulation during an unusual session with a patient he had been treating with spinal manipulations. On a return visit, Barral noted appreciable improvement in the patient's range of motion. The patient confirmed that he felt relief from his back pain after going to an "old man who pushed something in my abdomen", a statement which piqued Barral's interest in the relationship between the viscera and the spine. He subsequently began to explore stomach manipulations with several patients, with successful results, leading him to develop visceral manipulation [2].

With the help of the radiologist Serge Cohen, Barral also documented changes in the viscera before and after manipulation, employing x-ray fluoroscopy and ultrasound to record changes in position and motion, as well as fluid exchange and evacuation [2]. Cohen and Barral also conducted additional research with a team of electrical engineers and technicians using infrared emissions from the body [2].

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REFERENCES

1. Harvey A. A pathway to health: how visceral manipulation can help you. Berkeley, CA, USA: North Atlantic Books; 2010.

2. Barral J-P, Mercier P. Visceral manipulation. Seattle, WA, USA: Eastland Press; 1983.

3. Kronke K. A questionnaire to evaluate the professional field of osteopathy in Austria; pilot study. [Thesis]. Vienna, Austria: Wiener Schule fur Osteopathie; 2003. DELETE

Visceral manipulation is used to locate and release dysfunctional patterns throughout the body that restrict movement and decrease vitality. It encourages the patient's own natural mechanisms to improve the functioning of organs, dissipate the negative effects of stress, enhance mobility of the musculoskeletal system through the connective tissue attachments, and influence general metabolism.

Therapists using visceral manipulation assess the dynamic functional actions as well as the somatic structures that perform individual activities. They also evaluate the quality of the structures (including the muscles, fascia, organs, and fluids) and their functions in relation to an overall harmonious pattern, with motion serving as the gauge for determining quality.

Owing to the delicate and often highly reactive nature of the visceral tissues, it is suggested that a gentle, precisely directed force be used. As with other methods of manipulation that affect the body deeply, visceral manipulation works only to assist the self-healing forces already at work, and because of this, trained therapists who apply it appropriately will most likely benefit the body rather than adding further injury or disorganization.

Patients seek out visceral manipulation for a variety of disorders that affect the body's systems. These include:

• Acute disorders: whiplash, seat-belt injuries, and chest or abdominal sports injuries.

• Musculoskeletal disorders: somatic-visceral interactions, chronic spinal dysfunction, headaches and migraines, carpal tunnel syndrome, peripheral joint pain, and sciatica.

• Pain related to post-operative scar tissue, post-infection scar tissue, and autonomic mechanisms.

• Digestive disorders: bloating, constipation, nausea, acid reflux, gastroesophageal reflux disease, and swallowing dysfunctions.

• Women's and men's health issues: chronic pelvic pain, endometriosis, fibroids and cysts, dysmenorrhea, bladder incontinence, prostate dysfunction, referred testicular pain, and effects of menopause.

• Pediatric issues: constipation, gastritis, persistent vomiting, vesicoureteral reflux, colic, torticollis.

• Emotional issues: anxiety and depression and post-traumatic stress disorder.

Visceral manipulation returns physiologic motion to the tissues, thereby enhancing normal movement of the body, including the movement of the visceral structures in relation to each other and the motion within each structure. It also increases communication within the body through improved functioning of the nervous system, circulation, lymphatic, and respiratory systems by softening the fascia that surrounds each of these structures, thereby reducing pressure on them, as well as allowing better exchange of fluids. This improves the breakdown and removal of waste products, reduces inflammation and pain, and improves the delivery of hormones and chemicals to the cells [1]. By releasing and/or resolving a restriction of the tissue, including adhesions or scars, normal circulation can resume in the body. The rate of tissue repair is increased, as normal nerve function and associated axoplasmic transportation is restored in the area being treated [2].

Visceral manipulation can also aid mood and sleep, partly through the effect that serotonin levels have on these elements, which is increased through massage applications [3], and the role that the digestive system plays in making this hormone. Spasms in muscles can be released, thereby reducing or eliminating pain, as well as increasing joint flexibility. Overall, visceral manipulation re-establishes the body's ability to adapt and restore itself to health, balance, and vitality.

REFERENCES

1. Herman H, Cier JF. Precis de Physiologie. Paris, France: Masson; 1977.

2. Korr I. The neurobiologic mechanisms in manipulative theory. NY, USA: Plenum; 1978.

3. Field T, Hernandez-Rief M, Diego M, Schanberg S, Kuhn C. Cortisol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci. 2005;115(10):1397-1413.

Visceral manipulation is applicable in most clinical settings as it bridges the needs of various patient populations, and is performed by a wide variety of healthcare professionals. These include osteopathic practitioners, allopathic practitioners, doctors of chiropractic, doctors of Oriental medicine, naturopathic practitioners, physical therapists, occupational therapists, massage therapists, and other professionals licensed in bodywork.

Owing to the precise nature of visceral manipulation, this therapy is very effective at locating and treating the primary cause of pain or dysfunction. The evaluation techniques used in visceral manipulation, called 'general listening' and 'local listening', are the keystones to this modality. They assist the therapist in finding this primary restriction, as the therapist's 'listening' hands lie passively, sensing and evaluating subtle yet distinct movements of visceral mobility and motility, as well as fascial restrictions extending throughout the body. A restriction is an area of reduced flexibility that will pull the surrounding tissue toward it, and the therapist will feel this under their hands. The body 'hugs the lesion', meaning that when there is tension in the front of the body, it causes the body to bend forward, and when the tension is to one side, it causes the body to twist toward that side. The individual will look as if they are trying to wrap the body around the tense area, and the therapist can feel this tension pulling toward this restricted area.

Using anatomical knowledge together with skilled hands, the therapist is able to determine which structures the body is most concerned with at the time of examination, which may or may not be where the person is experiencing symptoms, but where the core or primary tension is located that is causing the symptoms. 'Listening' is used not only to guide the therapist to the areas that need treating, but also to allow the therapist to best feel how the tissues need to be released.

Through this very specific, localized treatment, broad-reaching positive effects can be seen throughout the entire body.

Visceral manipulation is a hands-on manual therapy that only requires the skillful application of the therapist's hands to evaluate and treat, along with an in-depth knowledge of anatomy.

The evaluation and treatment is carried out with the patient standing, or with the patient sitting or lying on a therapy table.

The treatment is through gentle compression, mobilization, and elongation of the tissues. The therapist may make deep contact with the body, but this contact should not be invasive and only rarely be painful.

Visceral manipulation aims to find and resolve tensions in the tissue and thereby restore normal motion to the tissue. A central guideline for visceral manipulation is to evaluate the person to find the structure that is causing the greatest problem for the body at that time. It may be different with each session, as the therapist focuses on what the patient's body most needs at that particular session.

At the initial consultation, the therapist should be able to give an idea of how often and for how long they will need to see the patient, and this will depend on the individual's condition and goals for treatment. In general, most people will notice change in 3-5 sessions, although for some very long-term or severe problems, it may be longer. Some problems will change rapidly and others more gradually, depending on the condition, how long it has continued, and how the body responds to treatment. In addition, the time between each session will vary depending on the condition, though the average is typically around one visit every 2-3 weeks, as this allows the tissues time to adjust between appointments. The sessions may also vary in length according to the therapist's style and the patient's needs. Sessions could be as short as 10 min (perhaps with a baby), or to up to 1 h or more in some cases.

Visceral manipulation aims to gently restore the body to optimum structure and function. To identify areas of restriction and how they need to be released, the therapist feels the tissues and their tensions (movie 1 and movie 2). This is known as 'listening' and is one of the most important tenets of visceral manipulation. As each person is unique, only by following an individual's body tensions can a therapist best determine how to help a particular body release them.

Organs move in three dimensions; therefore, restrictions occur in three dimensions. Hence, visceral manipulation treatment aims to restore motion in all three planes of motion: up and down, front to back, and side to side.

For structural problems, whether in the bony frame, soft tissues, or internal organs, the therapist finds the point that causes the greatest restriction to movement, or increases tension on the tissues, and releases this area. This in turn allows the affected tissues and compensatory patterns to return to normal function. This is an example of structure governing function, and in visceral manipulation terms, is known as the mobility of the tissues.

Likewise, where an organ has a functional problem, the therapist uses techniques, such as augmentation of subtle movements, to restore the normal intrinsic rhythm of the organ (known as motility) to allow the function to normalize. Motility can be reduced by an issue within the organ itself, such as inflammation, emotional concerns, or in relation to medication. In these cases, motility treatment restores the energy balance of the organ. Motility reduction may also be due to surrounding structures that have been binding an organ and impinging on its cellular motion. In these cases, motility treatment is used after mobility release to remind the organ of its inherent motion pathway.

Visceral manipulation aims to gently restore the body to optimum structure and function. To identify areas of restriction and how they need to be released, the therapist feels the tissues and their tensions (movie 1 and movie 2). This is known as 'listening' and is one of the most important tenets of visceral manipulation. As each person is unique, only by following an individual's body tensions can a therapist best determine how to help a particular body release them.

Organs move in three dimensions; therefore, restrictions occur in three dimensions. Hence, visceral manipulation treatment aims to restore motion in all three planes of motion: up and down, front to back, and side to side.

For structural problems, whether in the bony frame, soft tissues, or internal organs, the therapist finds the point that causes the greatest restriction to movement, or increases tension on the tissues, and releases this area. This in turn allows the affected tissues and compensatory patterns to return to normal function. This is an example of structure governing function, and in visceral manipulation terms, is known as the mobility of the tissues.

Likewise, where an organ has a functional problem, the therapist uses techniques, such as augmentation of subtle movements, to restore the normal intrinsic rhythm of the organ (known as motility) to allow the function to normalize. Motility can be reduced by an issue within the organ itself, such as inflammation, emotional concerns, or in relation to medication. In these cases, motility treatment restores the energy balance of the organ. Motility reduction may also be due to surrounding structures that have been binding an organ and impinging on its cellular motion. In these cases, motility treatment is used after mobility release to remind the organ of its inherent motion pathway.

'Lesion' is the osteopathic term for an abnormality in the tissue caused by disease or trauma, and includes the restriction of a tissue. A restriction in one part of the body does not remain isolated. Owing to the interconnectedness of the body via fascia, structure and the effects of gravitational forces, the transmission of pressure, movement, posture, and tension rapidly cause the restriction in one tissue to lead to a whole series of compensations and changes in other tissues of the body. For example, a problem may begin in the big toe, which then changes the dynamics of the foot and ankle, affecting gait and leading to pelvic imbalances. This, in turn, may lead to changes in the functioning of the pelvic organs, perhaps leading to constipation, dysmenorrhea [1], or abdominal pain, or changes in the spine, leading to neck pain or headaches [2]. This is what is known as a lesional chain, that is, the chain of reactions set off by one restriction or lesion. In many cases, a lesional chain may not have any symptoms as the body is still able to compensate for the pattern of tension. However, over time, the body is less able to compensate, and symptoms begin to appear as the body or organ decompensates. Lesional chains explain why a therapist can seem to be addressing parts of the body unrelated to the symptoms.

In visceral manipulation, the aim of the therapist is to find the start of the lesional chain and help to normalize that area, which may well resolve a number of residual problems that a restriction had caused.

REFERENCES

1. Herbert B. Chronic pelvic pain. In: Maizes V, Dog TL (Eds). Integrative women's health. Oxford, UK: Oxford University Press; 2010.

2. Ferrari R The chronic whiplash syndrome -- a case of attributional pathosis? Cephalagia. 2002;22(7):560-562.

With visceral manipulation, there are very few total contraindications to treatment; however, there are various contraindications for certain techniques, for different ages, and for certain conditions. If a therapist finds that there are signs of an acute infection, inflammation, or recent trauma, it is best to allow the body to deal with the current issue rather than giving it more changes with which to cope. Applied during a crisis, visceral manipulation could overload the body with information, but once the crisis has passed, it can be very useful in helping the body reassess the adaptations it made to cope at the time of the crisis. This can prevent residual compensations that might lead to restrictions or further problems later down the line.

Therapists are taught to act cautiously, and so may choose not to treat someone if they have cause for concern. Specifically, therapists should look for signs of serious disease that might be either life threatening or could deteriorate if not attended to immediately. This may be, for example, a tumor, a bleed in part of the body, a thrombosis, a perforated ulcer, enlarged lymph nodes, unexplained weight loss, aneurysm, a heart condition, or an infection. When working in the pelvic area, if there is suspected pregnancy or presence of an intrauterine device, treatment may not be appropriate at that time. However, each case is individual, and as long as therapists are aware of any possible circumstances that might mean there is a contraindication for visceral manipulation, they should judge all cases on their merits and the parts of the body that need treatment.